<p> HL7 Project ID: 178</p><p>Laboratory Test Result Abnormality Assessment CMET RMIM Data Dictionary</p><p>September 20, 2007 Version 0.4 Abnormality Assessment CMET RMIM & Data Dictionary The Abnormality Assessment CMET is used to communicate data about initial, first-level assessments of laboratory test results for indications of the presence and severity of an abnormal condition. </p><p>AbnormalityAssessment (COCT_RM120610VU01) Description:</p><p>AbnormalityAssessment classCode*: = "OBS" moodCode*: = "EVN" code*: CD CNE [1..1] <= V:ObservationType statusCode*: CS CNE [1..1] <= V:ActStatus activityTime*: TS.DATETIME [1..1] uncertaintyCode: CE CNE [0..1] <= V:ActUncertainty value: CD CWE [0..1] < ObservationValue methodCode: SET<CE> CWE [0..*] < ObservationMethod outcome typeCode*: = "OUTC" contextConductionInd*: BL [1..1] "True" 1..* assessmentOutcome </p><p>AssessmentOutcome AssessmentException classCode*: = "OBS" moodCode*: = "EVN" code*: CD CWE [1..1] <= V:ActCode value*: SC CWE [1..1] < ObservationValue GradeAnnotation AbnormalityGrade 0..1 gradeAnnotation classCode*: = "OBS" classCode*: = "OBS" appendage moodCode*: = "EVN" moodCode*: = "EVN" typeCode*: = "APND" code*: CD CWE [1..1] <= V:ActCode code*: CD CWE [1..1] <= V:ActCode contextConductionInd*: BL [1..1] "True" value*: SC CWE [1..1] < ObservationValue value*: CD CWE [1..1] < ObservationValue</p><p>AbnormalityAssessment The process of evaluating a clinical finding, including a laboratory test result, to detect the presence and severity of an abnormal condition, and to assign the corresponding descriptive terminology.</p><p>Attributes  ClassCode: a code that identifies Observation as the type of act.  MoodCode: a code that identifies Event as the type of mood.  Code: a code that specifies the type of observation as Adverse Reaction.  StatusCode: a coded value that specifies the action taken (aborted/invalid; cancelled/not assessed; completed/assessed and inconclusive) with respect to the assessment for abnormality.  ActivityTime: the date and time at which the automated assessment for abnormality was performed.  UncertaintyCode: a code that specifying whether the grade assignment has been asserted to be uncertain in any way.  Value: specifies the code system and coded value for the abnormality.  MethodCode: a code that provides additional detail about the means used to arrive at the assessment result.</p><p>HL7 Project ID: 178 | Laboratory Test Result Abnormality Assessment 2 of 3 Abnormality Assessment CMET RMIM & Data Dictionary AssessmentException This class represents one of two possible observation outcomes of an AbnormalityAssessment. A message provided to indicate that an assessment could not be executed or completed and to identify the reason for the failure.</p><p>Attribute  ClassCode: a code that identifies Observation as the type of act  MoodCode: a code that identifies Event as the type of mood  Code: a code that specifies the type of observation as Assertion  Value: a coded value and description specifying the reason an assessment could not be executed or completed and is provided with the assessment status code of aborted/invalid and cancelled/not assessed. </p><p>AbnormalityGrade This class represents one of two possible observation outcomes of the AbnormalityAssessment. The severity of the abnormality is based on a specified assessment scale.</p><p>Attribute  ClassCode: a code that identifies Observation as the type of act  MoodCode: a code that identifies Event as the type of mood  Code: a code that identifies the type of observation as Severity  Value: a coded value that represents the grade/level of severity associated with an assessed abnormality (grade 0 – 5).</p><p>GradeAnnotation Additional information provided about a grade that must be considered in order to determine the final grade.</p><p>Attribute  ClassCode: a code that identifies Observation as the type of act  MoodCode: a code that identifies Event as the type of mood  Code: a code that specifies the type of observation as Assertion  Value: text that provides additional information about the severity grade, which must be considered before determining the final grade.</p><p>HL7 Project ID: 178 | Laboratory Test Result Abnormality Assessment Messaging Specification 3 of 3</p>